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• I <br /> UNIFIED PROGRAM CONSOLIDATED F _ RM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILI <br /> j (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION V,.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) I' 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business AAS) 3 FACILITY IO X <br /> /YIfNI M c.9 �L `y <br /> NEAREST GROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCYIDISTRICT- <br /> ID 42"r, F 1. CORPORATION r 5. COUNTY AGENCY' <br /> BUSINESS TYPE rl�-GAS STATION r 3.FARM r 5.COMMERCIAL INDIVIDUAL 6. STATE AGENCY- <br /> 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER 3. PARTNERSHIP r 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or -If owner of UST is a ouolic agency:name of supervisor of <br /> REMAINING AT SITE trustlands7 division,section or office which operates the UST. <br /> e�7 (This is the Contact person for the tank records.) <br /> 404 \( r Yes o 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OE 407 PHONE a09 <br /> OWNER NAME Q <br /> MAILING OR STREET ADDRESS 409 <br /> ITS-4a tJ, �� r=�1 L STATE 411 ZIP C00 412 <br /> CITY 410 I _ <br /> PROPERTY OWNER TYPE INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 413 <br /> r I. CORPORATION [' 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> PHONE 415 <br /> TANK OWNER NAME 414 <br /> s 1UA-R- L <br /> MAILING OR STREET ADDRESS 416 <br /> STATE 418 ZIP CODE 419 <br /> CITY 417 �5d-0 S- <br /> TANK <br /> . <br /> tPFTANK OWNER Lyt INDIVIDUAL r 4. LOCAL AGENCY!DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION r 3 PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> I B1 1-1 1 IST STOP AGE EE <br /> TY(TK)HO 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r S. LETTER OF CREDIT r a. STATE FUND&CFO LETTER r 99. OTHER: 422 <br /> . INSURANCE r 6. EXEMPTION r 9. STATE FUND&CO <br /> Check one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Le(lat notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUR�O�F APPLICANj DATE,,OAS 7�v Z 424 PHONE _ -"olip 425 <br /> NAME OF APP ICANT(print) 425 TITLE APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br />